| Entity Name: | FLEMING ISLAND SURGERY CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 05 May 2005 (20 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 21 Oct 2022 (2 years ago) |
| Document Number: | L05000044741 |
| FEI/EIN Number | 202874196 |
| Address: | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| Mail Address: | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| ZIP code: | 32003 |
| County: | Clay |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1457428005 | 2006-11-29 | 2020-08-22 | 1670 EAGLE HARBOR PKWY, SUITE B, ORANGE PARK, FL, 320034806, US | 1670 EAGLE HARBOR PKWY, SUITE B, ORANGE PARK, FL, 320034806, US | |||||||||||||||||||||||||
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| Phone | +1 904-541-3048 |
| Fax | 9042157960 |
Authorized person
| Name | MS. TARA SHEA MCLAUGHLIN |
| Role | DIRECTOR OF CONTRACTING |
| Phone | 7277859800 |
Taxonomy
| Taxonomy Code | 261QA1903X - Ambulatory Surgical Clinic/Center |
| License Number | PENDING |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | STATE LICENSE NUMBER |
| Number | PENDING |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FLEMING ISLAND SURGERY CENTER 401(K) PROFIT SHARING PLAN & TRUST | 2023 | 202874196 | 2024-05-05 | FLEMING ISLAND SURGERY CENTER | 55 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 471637791 |
| Plan administrator’s name | ERISA FIDUCIARY SERVICES, INC. |
| Plan administrator’s address | 1373 VETERANS HIGHWAY, SUITE 10, HAUPPAUGE, NY, 11788 |
| Administrator’s telephone number | 6312490500 |
Signature of
| Role | Plan administrator |
| Date | 2024-05-05 |
| Name of individual signing | ERISA FIDUCIARY SERVICES |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| Shah, M.D. Arjav T | Agent | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| Name | Role | Address |
|---|---|---|
| Downer, M.D. Donald M | Manager | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| Pecoraro, M.D. Russell A | Manager | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| Levine Lawrence M | Manager | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| Wallace, M.D. William A | Manager | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| Name | Role | Address |
|---|---|---|
| Shah, M.D. Arjav T | President | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL, 32003 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2022-10-21 | Shah, M.D., Arjav T. | No data |
| REINSTATEMENT | 2022-10-21 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| LC AMENDMENT | 2015-03-24 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2007-05-03 | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL 32003 | No data |
| CHANGE OF MAILING ADDRESS | 2007-05-03 | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL 32003 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2007-05-03 | 1670-B EAGLE HARBOR PARKWAY, ORANGE PARK, FL 32003 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-05-01 |
| ANNUAL REPORT | 2023-03-20 |
| REINSTATEMENT | 2022-10-21 |
| ANNUAL REPORT | 2021-02-08 |
| ANNUAL REPORT | 2020-04-06 |
| ANNUAL REPORT | 2019-04-16 |
| ANNUAL REPORT | 2018-04-30 |
| ANNUAL REPORT | 2017-04-26 |
| ANNUAL REPORT | 2016-03-30 |
| ANNUAL REPORT | 2015-04-07 |
| Inspection Nr | Report ID | Date Opened | Site Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 339555161 | 0419700 | 2014-01-21 | 1670 EAGLE HARBOR PKWY. SUITE B, ORANGE PARK, FL, 32003 | |||||||||||||||||||||
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| Type | Inspection |
| Activity Nr | 957684 |
| Health | Yes |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
